2.0 Analysis 2.1 Heading of the SERSOU Statements made by the navigation personnel on the SERSOU (the OOW and the helmsman) disagreed with statements made by other witnesses on three main points: the intended course of the SERSOU, the location of the collision, and whether the SERSOU was swinging to port across the channel or not. With regard to the intended course, the pilot said that the heading was 024 G while the navigation personnel said that it was 034 G. The orientation of the channel in that vicinity is 021-201. As the channel is only 244 m wide, a vessel of the size and draught of the SERSOU at eight knots could not maintain a heading 12 off the direction of the channel for longer than two and a quarter minutes without running out of the channel and grounding. A heading of 024 would have achieved the desired goal of bringing the SERSOU gradually over to the starboard side of the channel. Further, had the SERSOU been on a heading of 034, her port side would have been open when viewed from the SILVER ISLE. The personnel involved with the navigation of the SILVER ISLE, who had an unrestricted view of the SERSOU from a distance of about one mile, said that the port side of the SERSOU was not open. It is considered that 024 is the most likely course that the pilot had ordered the helmsman to steer. With respect to the position of the collision, the navigation personnel on the SERSOU stated that it occurred at Cap Saint-Michel, the location from which the SILVER ISLE had called in to the VTS at 1747, 18 minutes before. The pilot on the SERSOU and those involved with the navigation of the SILVER ISLE agreed that the collision took place in the vicinity of the le Sainte-Thrse light, and this was confirmed by the VTS. It is not considered that there is any doubt that the collision occurred near the le Sainte-Thrse light. Had the SERSOU been where her navigation personnel believed her to be, in the vicinity of Cap Saint-Michel, a course of 034 would have been appropriate for a downbound vessel. The pilot of the SERSOU stated that the vessel had picked up a sheer or a swing to port, but the OOW and the helmsman said that she had not. The personnel involved with the navigation of the SILVER ISLE agreed with the version of events as given by the pilot of the SERSOU based on their continuous monitoring of the aspect of the SERSOU. The SERSOU had just completed a minor course alteration to port and the pilot had found she was carrying 15 of port helm before he ordered the wheel hard over to starboard. The navigation personnel on the vessel had demonstrably not been monitoring the vessel's progress down the river properly. The OOW believed that the vessel was some three miles further downstream and, therefore, he was not in a position to appreciate whether or not the vessel had swung past the line of the axis of the channel. Based on the above, it is considered that, after rounding on to the Chenal le Sainte-Thrse, the SERSOU had swung past the intended heading, and to port of the alignment of the channel. This caused concern to the pilot on the SERSOU and to those in charge of the navigation of the SILVER ISLE and convinced them of the need to take action. 2.2 Change of Heading Experienced by the SERSOU A vessel navigating in a narrow channel may develop a swing or possibly a sheer as a result of four main factors: Bank cushion or bank suction can cause a vessel to swing because of unequal hydrodynamic pressure on the bow and stern. It is unlikely that the swing experienced by the SERSOU was caused by bank suction because the vessel was in the centre of the channel. Shallow-water effect can necessitate a greater- than-normal helm angle when altering heading and cause a sheer or swing when vessels are heavily laden. The SERSOU was proceeding at a speed of 8 kn through the water and 10.5 kn over the ground, and her under-keel clearance was approximately 2.05 m aft. At that speed and with that clearance, the SERSOU should not have experienced manoeuvring difficulties. A localized cross-current can have an impact on only a portion of a vessel's hull. Reportedly, pilots had experienced such an effect previously in this area of the St. Lawrence River. Steering errors which can be made by an inexperienced or inattentive helmsman. As no course recorder data are available, it can only be concluded that the sheer or swing experienced by the SERSOU was probably the result of one or both of the last two factors. 2.3 Collision Avoidance Options Besides the actions taken, there were other options available to both vessels that might have allowed them to avert the collision. 2.3.1 SILVER ISLE According to the Collision Regulations, the SILVER ISLE was the give-way vessel. She was also the more manoeuvrable of the two vessels. One of the options available to the SILVER ISLE would have been to reduce speed, thus giving those on the SERSOU more time to control their vessel's swing before the vessels met. Another option would have been to alter course to starboard, even to the point of going outside the channel. The water level was high at the area of impact, and the SILVER ISLE, in her light condition, had sufficient sea-room outside the channel for a safe port-to-port passage. A third option would have been a combination of course and speed alterations. 2.3.2 SERSOU The SERSOU was the stand-on vessel and had the right and responsibility to set the location and manner of passing. She was also, by far, the more heavily laden of the two vessels. Nonetheless, the pilot of the SERSOU allowed the pilot of the SILVER ISLE to persuade him to change the passing arrangement when he was already taking steps to correct the swing which had been picked up by the SERSOU. The SERSOU, which was proceeding at half-speed, had plenty of power in reserve that could have been used to improve the effectiveness of the vessel's rudder and thereby accelerate her response to the correction of the swing. 2.4 Action by the Master of the SILVER ISLE When the master of the SILVER ISLE arrived on the bridge after being summoned by the OOW, he found his vessel and the SERSOU two to three cables apart, in a close-quarters situation. The SILVER ISLE was swinging to port and the SERSOU was still swinging slowly to starboard toward the south side of the channel, across the path of the SILVER ISLE. As the OOW could not fully explain what was going on since the passing arrangements had been made in French, a language that he did not understand, and as the pilot, who had the conduct of the vessel, was fully occupied in talking on the radio and trying to avert a collision, the master could not gain a full understanding of the developing situation as it existed. His immediate assessment was that the two vessels could not clear each other and pass starboard-to-starboard. Therefore, using his best professional judgement, and without knowing that the wheel of the SERSOU was hard over to port, he ordered an immediate turn to starboard, effectively countermanding the pilots' agreed-upon procedure. 2.5 Sounding the General Alarm When the master of the SILVER ISLE sounded the general alarm, he provided valuable warning time to crew members who were in the cabins and the lounge on the port side aft. That part of the SILVER ISLE sustained heavy damage in the collision. The master's action likely saved lives. 3.0 Conclusions 3.1 Findings As the two vessels closed for a normal port-to-port meeting, the deeply laden SERSOU developed a swing to port. The cause of the vessel swinging to port was not determined. The SERSOU was unable to correct the swing quickly and did not use reserve power to counteract it. The pilot of the SILVER ISLE insisted on a starboard-to-starboard passing arrangement. The pilot of the SERSOU, the vessel which had the right-of-way, at first resisted then agreed to the starboard-to-starboard passing arrangement. The master of the SILVER ISLE countermanded an order by his pilot without having a full understanding of the navigational situation at that moment and without notifying the SERSOU of his action. Other than changing heading, neither vessel took any action to avert a collision until their main engines were put astern immediately before the collision. The collision situation developed in somewhat less than two minutes. The vessels' course recorders were not operating, and there is no regulatory requirement that they should have been. The OOW of the SERSOU did not know the precise position of his vessel. 3.2 Causes The SERSOU and the SILVER ISLE collided primarily because the SERSOU developed a swing such that she was heading across the track of the SILVER ISLE as the two vessels were meeting. A contributing factor was the demand by the pilot of the SILVER ISLE that the vessels change to a non-conventional starboard-to-starboard passing arrangement under conditions of uncertainty and confusion as to whether such passing arrangement was finally agreed to before the vessels were in a situation of extremis. The situation was further complicated when the master of the SILVER ISLE, called to the bridge late in the sequence of events, countermanded the orders of the pilot without having a full appreciation of the immediate situation and without notifying the SERSOU. 4.0 Safety Action 4.1 Action Taken 4.1.1 Bridge Resource Management In four previous occurrence reports, the Board has expressed its concerns about the adequacy of bridge resource management (BRM) practices on vessels in Canadian waters. Three of the four occurrences involved foreign vessels, one involved a Canadian vessel6. A general lack of interaction between the officer of the watch (OOW), master and pilot on the bridge, interrupted procedures, inadequate bridge-to-bridge communication, lack of situational awareness and of teamwork between the pilots and ships' officers, etc. have been contributing factors in such occurrences. Recognizing the need for improved BRM practices, at least one large Canadian shipping company is currently implementing a formal BRM training program for its officers. In view of the frequency of occurrences of a similar nature, the Board is currently studying the operational relationships between ships' masters, 6 The Yugoslavian bulk carrier MALINSKA (TSB Report #M91C2009), the Swedish Ro-Ro/ container carrier CONCERT EXPRESS (TSB Report #M92M4023), the Norwegian chemical tanker LAKE ANINA (TSB Report #M90L3016), and the Canadian product tanker EASTERN SHELL (TSB Report #M91C2008). OOWs and marine pilots. Based on the findings of this study, the Board will make appropriate safety recommendations to improve the effectiveness of BRM practices on both foreign and domestic vessels in Canadian waters.